Uterine Fibroids Overview

What Are Uterine Fibroids?

The medical term for uterine fibroids is uterine myomas or uterine leiomyomas. Myomas are non-cancerous tumors that grow in and around the uterus but where they originate from is not known. Normal smooth muscle cells of the uterus mutate into abnormal ones resulting in the formation of benign uterine tumors.

Fibroids can develop independently and can have one or multiple nodes within the uterus resembling rubber balls that vary in size. Many women with fibroids have no symptoms while others experience debilitating symptoms that significantly affect their quality of life.

What Causes Uterine Fibroids?

The exact cause of uterine fibroids is not known but research has indicated that genetics and excess estrogen play a part in the formation of fibroids. Elevated estrogen levels can cause fibroids to grow such as during pregnancy or when taking birth control pills that contain estrogen. After menopause when estrogen levels fall, fibroids can shrink and symptoms that are associated with fibroids usually dissipate.

Who Is At Risk For Fibroids?

Studies have shown patterns in women who develop fibroids. Some of the patterns discovered are:

• Some women are genetically predisposed to develop fibroids.
• Women between the ages of 30 and 40 have a higher incidence of fibroids.
• There is a link between the age a woman begins menstruating and fibroids.
• Women who start their cycle at a younger age are more likely to develop fibroids.
• Family history can be a factor in developing fibroids.
• African American women have higher instances of fibroids, they develop fibroids at younger ages, and their fibroids tend to be larger and greater in number.
• Obesity and high blood pressure can play a part in fibroid growth.
• Low vitamin D levels are a risk factor for developing fibroids.

What Are Symptoms Of Uterine Fibroids?

• Abnormally heavy and prolonged bleeding;
• Abdominal and/or pelvic pain;
• Increased urinary frequency and/or nocturia – waking up at night to urinate;
• Back or leg pain;
• Constipation and bowel issues;
• Pain during intercourse;
• Enlarged uterus and/or abdomen;
• Fertility issues.

Types Of Uterine Fibroids

Fibroids are often classified based on their location in the uterus. The three different types of fibroids are submucosal, subserosal, and intramural. Submucosal and subserosal fibroids can be sessile (broad base of attachment to the uterus) or pedunculated (attached by a thin stalk). Fibroids can range in size from as small as a pearl to as large as a melon.

Submucosal fibroids are the rarest type of fibroids and numerous studies have indicated that submucosal fibroids, of any size, are the greatest contributors to female infertility issues.

These benign growths can develop individually or in clusters, possibly deforming the uterine wall and causing issues for a woman who is trying to conceive. If the submucosal fibroids grow large or too numerous, the fallopian tubes can become blocked or the embryo may be unable to attach to the uterine wall. Submucosal fibroids are also associated with heavy menstrual bleeding often leading to anemia.

Subserosal fibroids grow underneath the outer covering of the uterus and can be embedded in the muscle of the uterus or attached to the outside of the uterus via a peduncle – a narrow stalk or stem. Since subserosal fibroids grow away from the uterus (i.e. they don’t affect the lining or the uterine cavity), they do not often cause the heavy bleeding associated with the submucosal and large intramural fibroids. As they grow, subserosal fibroids cause bulk-related symptoms by pressing on whatever organ or structure is next to them. Symptoms can include pelvic pain, bloating, sciatica, increased urinary frequency, pain during intercourse, and constipation.

Intramural fibroids are the most common and grow in the muscle tissue of the uterus and can cause either the bleeding symptoms associated with the submucosal fibroids or the bulk-related symptoms associated with the subserosal fibroids or both depending on which way these fibroids grow.

Some women experience lower back and pelvic pain due to large fibroids pressing on the spine or other organs. Large anterior fibroids can exert pressure on the bladder and cause or waking multiples each night to urinate. Posterior intramural fibroids can press on adjacent bowel loops causing constipation. Large or numerous fibroids can cause the abdomen to protrude and can also affect fertility and the ability of a woman, who does become pregnant, to carry the baby to term.

How Are Uterine Fibroids Diagnosed?

Most often fibroids are discovered at a routine physical examination and then confirmed by a pelvic ultrasound exam.

A pelvic ultrasound is an imaging tool that uses sound waves emitted from a probe that is either placed on the skin (transabdominal probe) or inserted in the vagina (transvaginal probe). These waves are turned into images that are displayed on a black and white screen. However, the resolution of the ultrasound is significantly lower than a pelvic MRI.

Pelvic MRI historically was cost-prohibitive and since almost every OB-GYN owned an ultrasound machine this lower-cost alternative was routinely used. Today an MRI is more affordable and the resolution produces far superior images making it the most preferred method to diagnose uterine fibroids.

Other imaging tests that can be used include:

Sonohysterography is also known as hysterosonography or saline infusion sonogram. Sterile saline is used to open up the uterine cavity allowing easier access to get images of submucosal fibroids and the lining of the uterus.

Hysterosalpingography uses dye to highlight the uterine cavity and fallopian tubes on X-ray images. This test can help your doctor determine if your fallopian tubes are blocked and can also often reveal submucosal fibroids.

Hysteroscopy – a small, lighted telescope, called a hysteroscope, is inserted through the cervix into the uterus. Next, saline is injected into the uterus, expanding it and allowing your doctor to examine the walls and the openings of the fallopian tubes.

Treatments For Fibroids

Gonadotropin-releasing hormone (GnRH) agonists or antagonists are hormone treatments that medically create premature menopause by lowering the body’s estrogen level and temporarily shrinking fibroids. These drugs come with undesirable side effects and are not recommended for use longer than 6 months. They are also very expensive and fibroid growth is only suppressed while taking the medication so they return and grow as soon as the medication is stopped.

Myomectomy is a surgical method to remove fibroids and is performed by a gynecologic surgeon, in a hospital under general anesthesia. A myomectomy is most commonly done via an incision in the abdomen (open myomectomy) but can also be performed vaginally through a scope inserted into the vagina (hysteroscopic myomectomy) or through small incisions made in the abdomen (laparoscopic myomectomy).

A myomectomy requires a 1-3 days hospital stay and an overall recovery time of 4-8 weeks. Risks include damage to nearby organs or the uterus, excessive bleeding requiring a blood transfusion, infertility issues, may weaken the uterus so full-term pregnancy may not be possible, if pregnancy does occur it would require a C-section to deliver, new tumors often grow and therefore it has a high recurrence rate 11% per year.

Hysterectomy is a surgical procedure that removes the entire uterus, and can also include the cervix, one or both ovaries, and fallopian tubes. A hysterectomy requires a hospital stay and a recovery time of 6-8 weeks. Risks include damage to other nearby organs such as the bladder, urethra, blood vessels, and closely associated nerves, blood loss, blood clots, increased risk of sexual dysfunction such as loss of libido or orgasm, urinary leaking, bone loss leading to osteoporosis, and increased cardiovascular risk. After a hysterectomy, a woman can not become pregnant.

Uterine Fibroid Embolization (UFE) is a non-surgical, outpatient minimally invasive procedure that is 90% effective in relieving fibroid symptoms. The procedure stops the blood flow to all of the fibroids and causes them to shrink and/or die off. UFE does not require a hospital stay, yields permanent results, and patients are discharged the same day as the procedure with just a bandaid. The recovery time is about 5-7 days. Many patients have successfully become pregnant after the UFE procedure.